Otolaryngol Clin N Am 36 (2003) 359–381 Alternative medications and other treatments for tinnitus: facts from fiction Michael D. Seidman, MDa,*, Seilesh Babu, MDb aDepartment of Otolaryngology–Head and Neck Surgery, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA bProvidence Hospital, 22279 Arbor Lane, Farmington Hills, MI 48336, USA Since the dawn of human existence, nutritional supplements, herbs, and phytonutrients have been used to heal. Forty percent of Americans haveused some form of complementary-integrative medicine (CIM) to treata wide variety of chronic conditions. In 1998, expenditures on CIM in theUnited States approached $27 billion and increased to $32 billion in 2000[1]. This paradigm shift to alternative forms of therapy is gaining acceptancefor many reasons including patients' dissatisfaction with conventional medi-cal care, which is perceived to be too intent on curing rather than prevent-ing disease, and the fact that prescription medicines have many side effectsand hence, patients are often con-compliant. Conversely, the conventionalwestern physician is typically skeptical of CIM practices because of the lack ofdouble-blind randomized placebo-controlled studies. This is a particularly dif-ficult problem because the pharmaceutical industry is not routinely interestedin funding studies to assess the efficacy of herbs and other supplementsbecause patent protection is unlikely. Coupled with the fact that the cost tobring a compound through the US Food and Drug Administration averages$300 million or more, it is no wonder that studies into this arena are rare [2].
Conventional medical fields, such as allopathic and osteopathic medicine, were only introduced in the United States less than 200 years ago. Thissubsequently led to the rapid reduction in CIM therapies because these weresuddenly viewed as antiquated and a form of quackery. The unfortunateresult of this skepticism was the overemphasis solely on conventional medi-cine as a means to heal and cure. In the best scenario, tapping into knowl-edge from both CIM and conventional medicine would likely lead to betteroverall care of patients.
* Corresponding author.
E-mail address: [email protected] (M.D. Seidman).
0030-6665/03/$ - see front matter Ó 2003, Elsevier Science (USA). All rights reserved.
doi:10.1016/S0030-6665(02)00167-6 M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 The use of medication for treatment of tinnitus has largely been varied and anecdotal. Such drugs as nicotinic acid, carbamazepine, baclofen, and othershave been tried and even tested in double-blind placebo-controlled trials(Table 1) [3]. Few have been shown to be significantly beneficial in adequatelydesigned studies. Lidocaine has been studied in several carefully controlleddouble-blinded studies and shown to be beneficial. Lidocaine, however, mustbe given intravenously, has a very short half-life, and is often accompanied byundesirable side effects. Oral analogs of lidocaine, such as tocainide andflecainide acetate, did not improve tinnitus [4]. A double-blind, placebo-controlled study using melatonin (3 mg at bedtime) was found to have noadvantage over placebo in relieving tinnitus. Among patients reportingdifficulty sleeping attributable to their tinnitus, however, 46.7% reportedan overall improvement after melatonin compared with 20% for placebo [4].
Benzodiazepines also may provide relief, especially for patients with con-current depression. In one study, 76% of patients taking alprazolam had areduction in the loudness of their tinnitus, whereas only 5% of the placebogroup showed benefit [5]. Education, counseling, tinnitus retraining therapy,and medications remain the major modalities in the treatment of tinnitus.
Many individuals have reported that these have provided either resolution of,or produced the greatest decrease in, their symptoms.
This article discusses treatment alternatives for chronic tinnitus. Examples include variations in diet, vitamin supplementation, herbal medicine, andother modalities. Although these options are considered alternative to manytraditional physicians, it should be emphasized that there is currently nocure for tinnitus. The treatments discussed in this article have been beneficialfor some people who have constant tinnitus, especially those whose tinnitusfailed to respond to traditional treatment modalities. Altering one's diet hasbeen shown to improve tinnitus in some patients. Many patients with tin-nitus report that certain supplements seem to have a variable benefit in re-ducing their symptoms. Nutrient supplementation to treat tinnitus has beenextensively studied. The following have generated the most interest and sup-port: magnesium, calcium, potassium, lipoflavonoids, B vitamins, copper,selenium, zinc, and manganese. Herbal remedies for this ailment includeGinkgo biloba, black cohosh, mullein, and cornus. Other treatments, suchas laser-light therapy, enzymatic therapy, tinnitus retraining, and vibra-tional therapy, are also discussed.
Vitamin B complex The B-complex vitamins are a family of nutrients that have been grouped together because of the interrelationships in their function within humanenzyme systems, and their distribution in natural food sources. Deficiency inthese vitamins has been shown to result in tinnitus [6], and supplementationmay improve the symptom. The B vitamins are water soluble and easilyabsorbed, except vitamin B12, whose absorption is enhanced by intramus- M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 Table 1Medications used to treat tinnitus Lidocaine/lignocaine (Xylocaine IV)Procaine (Novocain IV)Tocainide (Tonocard)-oral lidocaine analogueFlecainide acetate (Tambocor) Nortriptyline (Pamelor)Paroxetine (Paxil)Fluoxetine (Prozac)Sertraline (Zoloft)Bupropion (Wellbutrin)Amitriptyline (Elavil) Carbamezapine (Tegretol)Phenytoin (Dilantin)Primidone (Mysoline) Anti-axiety Agents Alprazolam (Xanax)Clonzaepam (Klonopin)Diazepam (Valium) Baclofen (Lioresal) Furosemide (Lasix) Vasoactive medications Ginkgo bilobaBlack cohoshLigustrumMulleinPulsatillaSt. John Wort Vitamins and minerals Magnesium (400 mg d)Calcium (1000 mg/d)Potassium (2500 m/d)ZincManganeseCopperVitamin B12Beta caroteneSeleniumVitamin CVitamin ENiacin cular injection or sublingual application. Nevertheless, oral B12 supplemen-tation still leads to increased serum levels. Unlike fat-soluble nutrients, mostB-complex vitamins cannot be stored in the body, and must be replaceddaily from food sources or supplements.
M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 The B vitamins function as coenzymes to facilitate human metabolism and energy production. They maintain healthy skin, eyes, muscle tone, andsupport the functions of the liver and central nervous system. They are alsoimportant in helping to deal with depression, stress, and anxiety. Normally,B vitamins are taken as a complex, but a single B vitamin may be indicatedto treat a particular disorder. Deficiency in B vitamins may also result inlethargy, anemia, nervousness, skin and hair problems, decreased appetite,poor night vision, and hearing loss [7].
Vitamin B1 (thiamine) Vitamin B1 (thiamine) is a nutrient with a critical role in maintaining a healthy central nervous system. Adequate thiamine levels can dramaticallyaffect cognitive function by maintaining a positive mental attitude andenhancing learning abilities. Conversely, inadequate levels of B1 can lead tovision problems, mental confusion, and loss of physical coordination.
Vitamin B1 is required for the production of hydrochloric acid, forming blood cells, and for maintenance of healthy circulation. It also plays a keyrole in converting carbohydrates into energy, and in maintaining propermuscle tone of the digestive and cardiovascular systems. A chronic defi-ciency of thiamine leads to beriberi, a devastating and potentially deadlydisease of the central nervous system. Beriberi is diagnosed clinically by per-ipheral neuropathy and cardiovascular and cerebral dysfunction, which in-cludes congestive heart failure and dementia. Because of improved diets andthe widespread use of supplements, beriberi is rare in developed countries,with one important exception. Beriberi symptoms are occasionally seenin chronic alcoholics because of the destructive effect alcohol has on B1.
Thiamine levels can also be affected by ingestion of antibiotics, sulfa drugs,caffeine, antacids, and oral contraceptives. A diet high in carbohydratescan also increase the need for B1.
Food sources high in thiamine include beans, eggs, brewers yeast, whole grains, brown rice, and seafood. In supplemental form, B1 is generally foundin a combination with vitamins B2, B3, B6, pantothenic acid, and folic acid.
There are no known toxic effects from vitamin B1, and any excess is excretedfrom the body. The recommended dietary intake (RDI) for B1 is 1.5 mg,although more typical daily intake ranges from 50 to 500 mg/d [8].
Some patients have noted that vitamin B1 supplements relieve their tinnitus [9]. The mechanism of action seems to be by a stabilization effect onthe nervous system, especially in the inner ear. Dosages ranging from 25 to500 mg/d have been used.
Vitamin B3 (niacin) Vitamin B3 (also called niacin, niacinamide, or nicotinic acid) is an essential nutrient required for proper metabolism of carbohydrates, fats, M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 and proteins, and for the production of hydrochloric acid. Vitamin B3 alsosupports circulation, healthy skin, and aids in the functioning of the centralnervous system. Because of its role in supporting the higher functions ofthe brain and cognition, vitamin B3 also plays an important role in thetreatment of schizophrenia and other mental illnesses, and in stabilizingcognitive functions. Adequate levels of B3 are vital for the proper synthesisof insulin, and the sex hormones, estrogen, testosterone, and progesterone.
Natural food sources for vitamin B3 include beef, broccoli, carrots, cheese,corn flour, eggs, fish, milk, potatoes, and tomatoes. Foods containingvitamin B3, however, provide minimal amounts of this vitamin.
A deficiency in vitamin B3 can result in pellagra, a disorder characterized by malfunctioning of the nervous system and gastrointestinal upset.
Classically, the three cardinal symptoms are diarrhea, dementia, anddermatitis. Recently, niacin has been embraced by the medical communityfor its ability to safely lower cholesterol and triglyceride serum levels. Thedosing required is between 500 and 2000 mg daily. Doses exceeding 1000 mgcan lead to hepatoxicity and are more common in the timed-release niacinsupplements. When recommending doses in this range, liver function testsneed to be monitored [8].
Niacin at any dose may result in a niacin flush, a natural reaction that is harmless but can be uncomfortable. A niacin flush generally results ina burning, tingling, and itching sensation, accompanied by a reddening flushthat spreads across the skin of the face, arms, and chest, typically lasting 5 to60 minutes [8]. A nonflush form of niacin now exists, which may be bettertolerated by some patients, but this is the form that is more apt to causepotential liver problems.
There is no accepted standard niacin dosing for tinnitus. Typically, the senior author recommends beginning at 50 mg twice a day. After 2 weeks, ifthere is no improvement, the patient increases the dose by 50 mg at eachinterval to a maximum dose of 500 mg twice per day. Higher doses can berecommended, but it is advised to monitor liver function tests. Niacin mayprovoke migraine headache attacks in some people and appropriate warningis justified. High doses should be used with caution in pregnant women.
Mega doses of pure niacin can aggravate health problems, such as stomachulcers, gout, glaucoma, and diabetes mellitus.
Unfortunately, there is no clinical proof for the effectiveness of niacin in treating tinnitus. This is inherently difficult to prove because of a possibleplacebo effect arising from the niacin flush sensation rather than anytherapeutic value of the underlying vasodilation. The senior author hasnoted a favorable response to niacin in some patients. There have been otheranecdotal reports of the benefit of niacin in treating tinnitus [9].
Some health care providers advocate taking niacin in combination with thiamine. The 1994 text on myofascial pain, Trigger Points, states that niacinwithout thiamine seems to provide little relief for tinnitus [10]. This has not,however, been the senior author's experience. The combination dosing is M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 two parts niacinamide for each one part thiamine. Some supplements comebalanced in this proportion.
There have also been reports of niacin working in combination with lecithin, a group of phospholipids that yield two fatty acid molecules andone molecule each of glycerophosphric acid and choline after hydrolysis.
Lecithin is found in nervous tissue, especially myelin sheaths, and in theplasma membrane of plant and animal cells. The theory is that the lecithin,being an emulsifier, helps disperse the buildup of fats in the capillaries, andthe niacin helps dilate the capillaries to allow the lecithin in. The phospha-tidylcholine portion of lecithin, however, is a precursor of acetylcholineand should be avoided in people who are manic-depressive because it mayworsen the depressive phase. Compelling evidence exists from experimentsin the authors' laboratory demonstrating that aged rats supplemented witha diet rich in phosphatidylcholine have improved auditory sensitivity whencompared with placebo-supplemented rats. Furthermore, study of thesubjects' mitochondrial function reveals a statistically significant improve-ment in mitochondrial energy production in the treated groups comparedwith placebo (Seidman et al, [11]).
Vitamin B12, also referred to as cobalamin and cyanocobalamin, is a micronutrient that is water soluble like other B vitamins. Unlike the other Bvitamins, however, which are not stored in the body, vitamin B12 is storedfor up to 9 months in the liver and kidneys.
The RDI for vitamin B12 is 2 lg for adults, 2.2 lg for pregnant women, and 2.6 lg for nursing mothers [12]. Vitamin B12 is not found in vegetables,but can be found in pork, blue cheese, clams, eggs, herring, kidney, liver,seafood, and milk.
It has been estimated that 5% to 10% of persons over the age of 65 years are deficient in vitamin B12. With newer and more sensitive tests available,deficiency states have been found in as many as 15% to 20% of thepopulation [13]. This deficiency state is most likely secondary to absorptiondifficulties and a deficient nutritional intake. There may be some correlationbetween the decline in vitamin B12 levels and the increasing prevalence oftinnitus in the elderly.
Vitamin B12 is an important coenzyme required for the proper synthesis of DNA and new cell formation. It also works synergistically with vitamin Cto aid in proper digestion and absorption of foods, protein synthesis, andthe normal metabolism of carbohydrates and fats. Additionally, B12 pre-vents nerve damage by contributing to the formation of the myelin sheath.
Vitamin B12 also maintains fertility, and helps promote normal growth anddevelopment in children.
Metabolites, including cobalamin, are involved in stabilizing neural activity. Vitamin B12 is an essential cofactor for methylation of myelin basic M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 protein and cell membrane phospholipids. Cobalamin deficiency has beenshown to be a factor involved in neuronal dysfunction. It is logical toassume that a relationship between tinnitus, which might involve neuronaldysfunction, and vitamin B12 deficiency may exist. In the senior author'sexperience, several patients who were motivated to attempt nutritional sup-plementation with B12 noted significant improvement in their tinnitus.
Still others, however, have reported no such benefit.
A deficiency of vitamin B12 can result in pernicious anemia, characterized by megaloblastic anemia, lack of intrinsic factor, inability to absorb vitaminB12, and increased risk for esophageal webs and cancer. Because vitamin B12can be stored easily in the body and is only required in minute amounts,symptoms of severe deficiency usually take 3 to 5 years to appear. Whensymptoms do arise, usually in mid-life, it is likely that deficiency was causedby digestive disorders or malabsorption rather than poor diet. It is wellknown, however, that the elderly have a reduced dietary intake, which maypredispose them to nutritional deficiencies. Furthermore, strict vegetarians(vegans) who do not consume any foods of animal origin need to supple-ment their diets with this nutrient because B12 comes almost exclusivelyfrom animal sources.
Vitamin B12 is available in supplemental form. Because of relatively poor gastric absorption, B12 can be taken as a sublingual tablet or by in-jection. Supplements range in strength from 50 lg to 2 mg. Megadose vita-min B12 toxicity is unknown, and any excess is excreted from the body[14]. One can measure serum B12 or serum methylmalonic acid for levelsof this vitamin. The normal range of B12 in the healthy population is 150to 900 pg/mL.
Experimental studies and clinical observations have related tinnitus to demyelination of nerve fibers and to a distorted resting state of spontaneousneural activity. Shemesh et al [14] showed a high prevalence (47%) ofvitamin B12 deficiency in patients with chronic tinnitus when a criterion ofdeficiency is set at 250 pg/mL and lower. Serum cobalamin deficiency wasmore widespread and severe in the tinnitus group associated with noiseexposure. This suggested a relationship between vitamin B12 deficiency anddysfunction of the auditory pathway. Deficiency also results in peripheraland central neurologic pathology. Decreased methionine production causedby cobalamin deficiency can lead to a sensory demyelinating neuropathy.
Abnormalities of the nervous system in the absence of hematologic disorders and normal results of the Schilling test have been reported in 28%of 141 consecutive patients with abnormally low serum cobalamin. TheSchilling test assesses the absorption of free cobalamin and also the absorp-tion of free cobalamin with intrinsic factor. In many instances, the actualcause of the deficiency is difficult to identify. It might be a result of inade-quate dietary intake, a minor alimentary dysfunction, or a nutrition-meta-bolic disturbance. Supplemental cobalamin was found to show some reliefin several patients with severe tinnitus [15].
M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 Vitamin B6 (pyridoxine) Vitamin B6 is a coenzyme involved in the metabolism of carbohydrates, fats, and proteins and the manufacturing of hormones, red blood cells,neurotransmitters, enzymes, and prostaglandins. It is also required for theproduction of serotonin, a neurotransmitter that controls mood, appetite,sleep patterns, and sensitivity to pain. A deficiency of vitamin B6 canquickly lead to insomnia and profound malfunctioning of the centralnervous system. Common symptoms of deficiency can include depression,vomiting, anemia, renal stones, dermatitis, lethargy, and increased sus-ceptibility to diseases caused by a weakened immune system [8]. Amongits many benefits include helping to maintain healthy immune systemfunctions, protecting the heart from cholesterol deposits, and preventingrenal stone formation. It is also beneficial in the treatment of carpal tunnelsyndrome, premenstrual syndrome, night leg cramps, allergies, asthma,arthritis, and dizziness [8].
Supplemental B6 is commonly used as a treatment for nausea, morning sickness, depression, and tinnitus. Natural foods that are highest in vitaminB6 include brewers yeast, carrots, chicken, eggs, fish, avocados, bananas,brown rice, and whole grains. The RDI for vitamin B6 is 2 mg/d. MostB-complex formulas contain between 10 and 100 mg of vitamin B6. Vitamin B6is one of the few vitamins that can be toxic. Doses up to 500 mg/d areuncommon but safe. Doses above 2 g/d however, can lead to irreversibleneurologic damage. Doses exceeding this level should not be used unless thepatient is under the treatment of a physician. Vitamin B6 supplementsshould not be taken by Parkinson's disease patients treated with L-dopa,because vitamin B6 can diminish the effects of L-dopa in the brain.
Most of the vitamin B–complex supplements seem to work on tinnitus in some patients by providing a stabilizing effect on the nerves centrally andperipherally. Only anecdotal evidence exists regarding this treatmentmethod.
Folic acid is a water-soluble nutrient belonging to the B-complex family.
The name is derived from the Latin word ‘‘folium,'' because this essentialnutrient was first extracted from green leafy vegetables, or foliage. Some-times referred to as vitamin M, folic acid was originally extracted fromspinach in 1941 and was found to be an effective treatment for macrocyticanemia [7].
Folic acid is a vital coenzyme required for RNA and DNA synthesis.
Adequate levels are essential for energy production and protein metabolism,for the formulation of red blood cells, and for the proper functioning of theintestinal tract. Furthermore, studies have demonstrated that folic acidreduces homocysteine levels and reduces the risk of heart disease [8].
M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 Additional studies revealed that maternal folic acid intake leads to a significant reduction in the incidence of fetal neural tube defects, such asspina bifida. This effect was noted with a daily folic acid intake of at least400 lg, the current RDI. Folic acid may also prove to be effective in theprevention and treatment of uterine cancer [16].
Folic acid deficiency affects all cellular functions, but most importantly it reduces the body's ability to repair damaged tissues and grow new cells.
Tissues with the highest rate of cell replacement, such as red blood cells, areaffected first, leading to anemia. Deficiency leads to sore tongue; cracking atthe corners of the mouth; gastrointestinal distress; diarrhea; and poornutrient absorption, leading to stunted growth, weakness, and apathy [8].
Folic acid deficiency is common and can develop within a few weeks tomonths of lowered dietary intake. The greatest need for increased folic acidintake is in those who are under mental and physical stress, such asalcoholics, and people taking oral contraceptives, aspirin, or anticonvul-sants. Foods highest in folic acid include barley, beans, beef, bran, brewersyeast, brown rice, cheese, chicken, green leafy vegetable, milk, salmon, tuna,wheat germ, and whole grains.
Although not generally regarded as toxic, large doses of folic acid can cause allergic skin reactions and should be avoided by people being treatedfor hormone-related cancers. High doses of folic acid can also cause prob-lems in those taking phenytoin for a convulsive disorder. Folic acid seemsalso to have a stabilization effect on the nervous system. This might explainthe anecdotal evidence regarding the supplementation of folic acid in certainpatients to alleviate their tinnitus. The dosages used ranged from 400 to 800lg/d and usually required 2 to 3 months of trial to achieve results [9].
Zinc is a component of over 100 enzymes. Among these are DNA polymerase, RNA polymerase, and tRNA synthetase. Mild deficiencycauses growth retardation in children. More severe deficiency is associatedwith growth arrest, hypogonadism, infertility, poor wound healing,diarrhea, dermatitis, alopecia, behavioral changes, taste and smell disorders,and tinnitus. Zinc seems to function in certain areas to influence neuro-transmission and to inhibit binding of peptides and other ligands to theirneuroreceptors.
The RDI of zinc in adults is 15 mg. Most of the zinc content in humans is bound to proteins in the tissues. In plasma, zinc is primarily bound toalbumin; less than 2% of zinc is found free. The zinc level in serum is not thebest parameter, but is the most reliable one for assessing zinc balance in thebody. Nearly 99% of total-body zinc is inside the cells. The remainder is inplasma and extracellular fluids [17].
Studies on rodents have shown a high content of zinc in the inner ear.
Other studies have found that the human cochlea has the body's greatest M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 concentration of zinc. These findings have given rise to speculation of therole of zinc in inner ear function. A correlation between hypozincemia andtinnitus has been reported [18]. In an uncontrolled trial by Gersdorff et al[19], zinc was found to reduce tinnitus. Zinc given in doses ranging from10 to 25 mg has delivered good results in some patients shown to behypozincemic based on blood tests. In a double-blind, randomized study,Paaske et al [17] showed little correlation between hypozincemia andtinnitus, and no significant improvement in subjective tinnitus using zincsupplements.
Ochi et al [18] demonstrated a significant decrease in zinc levels in patients suffering from tinnitus, and that supplementation with doses of 34to 68 mg of zinc over 2 weeks significantly decreased tinnitus. Excellentresults have been found with the combination of niacin and 25 mg zincgluconate twice a day. If tinnitus is of recent onset, complete resolution ispossible. With longer duration, the tinnitus can be diminished with thesenutrients in some people.
Supplementation of 90 to 150 mg/d has been shown to be beneficial in some cases. Zinc therapy when prescribed is often accompanied by frequentblood tests to monitor copper levels. Copper and zinc compete for intestinalabsorption, so chronic ingestion of zinc may result in copper deficiency.
Acute zinc toxicity can usually be induced by ingestion of greater than 200mg of zinc in a single day and is manifested by epigastric pain, nausea,vomiting, and diarrhea.
By enhancing neural transmission, calcium supplementation has been shown to improve tinnitus symptoms in certain patients. Calcium is one ofthe most abundant minerals in the human body and accounts for between 2and 3 lb of total body mass. Adequate dietary sources are necessary forbuilding and maintaining strong bones and teeth and regulating musclegrowth. In conjunction with magnesium, calcium also plays a pivotal role inthe regulation of electrical impulses in the central nervous system and in theactivation of various hormones and enzymes required for proper digestionand metabolism. This vital mineral is also necessary to support bodilyfunctions, such as blood clotting and maintaining blood pressure. There isalso strong evidence that calcium plays a role in colon cancer, and thosewith low intake of calcium and vitamin D are more prone to this disease.
Half of America's adults are not getting enough calcium according to a panel of experts assembled by the National Institutes of Health. Thefederal committee estimates that calcium deficiencies, resulting in brittlebones and fractures, are costing the US health care system $10 billionannually. The report states that the recommended daily allowance forcalcium is too low, leading to weak bones in children, adults, and especiallyelderly women [8].
M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 Calcium absorption occurs primarily in the small intestines, and requires adequate amounts of vitamin D. The current RDI of calcium is 800 mgfor adults, 1200 mg for premenopausal women, and 1500 mg for post-menopausal women unless they are taking estrogen. Those with kidneydisorders should not take calcium supplements unless directed to do so bytheir health care professionals. Key dietary sources of calcium include dairyfoods, green leafy vegetables, and seafood. Absorption of dietary calciumcan be drastically reduced by consuming large amounts of such foods ascocoa; spinach; kale; rhubarb; almonds; and whole wheat products, whichare high in oxalic acid, and are known to interfere with calcium absorption.
Taking antibiotics, such as tetracycline, or aluminum-containing antacidscan also result in lower absorption of calcium. Alcohol, sugar, and coffeecan also affect the body's levels of this mineral.
Some patients have experienced improvement in their tinnitus after starting a regimen of vitamin and nutrient supplementation, which includedcalcium [9]. Dosages used ranged from 1000 to 1500 mg/d for several months.
Magnesium is the fourth most abundant cation in the body after sodium, potassium, and calcium, and the second most prevalent intracellular cation.
The normal body content is around 1000 mmol, 50% to 60% of which isin bone. Extracellular magnesium accounts for only 1% of total bodymagnesium. The normal serum concentration ranges between 0.75 and 0.95mmol/L [20].
Magnesium is essential for the function of important enzymes, including those related to the transfer of phosphate groups and every step related tothe replication and transcription of DNA and the translation of mRNA.
This cation is also required for cellular energy metabolism and has animportant role in membrane stabilization, nerve conduction, and iontransport. Deficiency can result in a variety of metabolic abnormalities andclinical consequences, including tinnitus [1].
Magnesium has been shown to prevent hearing loss in a study by Attias et al [1]. Three hundred healthy, young male military recruits undergoing 2months of basic training were studied. The trainees were repeatedly exposedto high levels of impulse noise. Each recruit received daily either 167 mgof magnesium (as magnesium aspartate) or a placebo (sodium aspartate).
Permanent hearing loss was significantly more frequent and more severe inthe placebo group. It can be inferred that magnesium may have a positiverole on tinnitus.
Magnesium is a potent glutamate antagonist. There is evidence in the literature that antagonism of glutamate receptors has an effect on auditorysensitivity and on tinnitus [8]. Furthermore, a highly motivated patientelected to have magnesium sulfate delivered to the inner ear for her severe M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 unilateral cochlear tinnitus. While the MgSO4 was being delivered, hertinnitus ceased. Unfortunately, it recurred shortly after cessation of theperfusion [9].
Animal studies have shown that noise exposure causes magnesium to be excreted from the body [20]. Supplementation with magnesium might reducethe ototoxicity from this noise and reduce the likelihood of new-onsettinnitus. Few studies have documented that magnesium supplementationimproves tinnitus, but many patients have had relief with this method.
Manganese is a mineral that is required in small amounts to manufacture enzymes necessary for the metabolism of proteins and fats. It also supportsthe immune system; regulates blood sugar levels; and is involved in theproduction of cellular energy, reproduction, and bone growth. Manganeseworks with vitamin K to support blood clotting and aids in digestion. As anantioxidant, manganese is a vital component of superoxide dismutase, anenzyme that is the body's main front-line defense against damaging freeradicals [21]. Although there is no RDI for manganese, the average intakeof manganese is between 2 and 9 mg/d. Foods high in manganese includeavocados, blueberries, nuts and seeds, seaweed, egg yolks, whole grains,legumes, dried peas, and green leafy vegetables.
Along with the B-complex vitamins, manganese helps control the effects of stress while contributing to ones' sense of well being, and it is possiblethat this may have a stabilizing effect on patients suffering from tinnitus. Adeficiency in intake can retard growth; cause seizures; lead to poor boneformation; impair fertility; cause birth defects; and lead to nervoussymptoms, such as tinnitus. Investigators are also looking at new linksbetween manganese deficiency and skin cancers. Anecdotal evidence hasshown that manganese supplementation may reduce the symptom oftinnitus [9].
Selenium is a component of several enzymes, most notably glutathione peroxidase and superoxide dismutase. These enzymes prevent oxidative andfree radical damage of various cell structures. Evidence suggests that theantioxidant protection conveyed by selenium operates in conjunction withvitamin E, because deficiency of one seems to enhance damage induced bya deficiency of the other. Selenium also participates in the conversion ofthyroid hormone to its active form.
The RDI is 50 to 70 l/d [7]. Deficiency is rare in North America. Such individuals have myalgias, cardiomyopathies, and nervous system abnor-malities. Keshan disease, a fatal heart disease found in children living in M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 certain sections of China, occurs where selenium intake is limited. Toxicityis associated with nausea, diarrhea, alterations in mental status, andperipheral neuropathy, observed in adults who inadvertently consumed be-tween 1500 and 2700 mg. One may check red blood cell glutathioneperoxidase activity, or plasma selenium concentrations for deficiency,although neither is entirely accurate [22]. Supplementation may take up to 6months to show improvement in symptoms, such as tinnitus.
Hyperbaric oxygen therapy Oxygen deprivation or reduced cochlear blood flow has been suggested as a potential cause of hearing loss and tinnitus in response to intense noiseexposure or secondary to sudden sensorineural hearing loss. Hyperbaricoxygen therapy may be considered in these situations. It may be moreeffective for recent-onset rather than long-term cases. Because tinnitus andhearing loss are not approved indications for the use of hyperbaric oxygentherapy, insurance does not normally cover the treatments. Hyperbaricoxygen therapy is commonly used in European countries for the manage-ment of sudden hearing loss and noise-induced hearing loss and the resultshave been positive [23].
The theory behind hyperbaric oxygen therapy treatment is based on the assumption that tinnitus is caused by reduced oxygenation to the inner ear.
Studies at Munich Technical University have shown that pure oxygentreatment under high air pressure can increase oxygen saturation in theinner ear up to 500%. In Russia this method reportedly has been used withsuccess for many years. In Moscow alone, there are about 40 pressurechambers in use for this currently [24].
Vinpocetine and vincamine Vinpocetine is a derivative of vincamine, which is an extract of the periwinkle. Although they have many similar effects, vinpocetine has morebenefits and fewer adverse effects than vincamine. It is a vasodilator andincreases blood flow to the brain and improves the brain's use of oxygen[25].
These drugs have not yet been approved for treatment in the United States; however, they are available in Europe and South America in over-the-counter preparations. Although not available in North America as apharmaceutical, they are available in low doses in over-the-counter supple-ments. Only anecdotal evidence exists that these medications can suppresstinnitus [9].
Vinpocetine is a derivative of vincamine and is three to four times more potent at improving cerebral circulation and is overall twice as potent asvincamine in humans. Vinpocetine has wide ranging effects and can be used M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 to treat stroke and improve memory, menopausal symptoms, maculardegeneration, impaired hearing, and tinnitus. The usual oral starting dose is40 mg three times daily, to be followed by a maintenance dose of one 20 mgtablet three times daily for a longer period of time. Vinpocetine has not beenreported to interact with other drugs.
In humans, the effect of vinpocetine on cerebral blood flow is uncertain, with some investigators reporting no change and others reporting anincrease. It has been reported that vinpocetine can be used safely to treatpatients with ‘‘chronic cerebral dysfunction of vascular origin.'' Vinpocetineis also a powerful memory enhancer. It facilitates cerebral metabolism byimproving cerebral microcirculation, enhancing brain cell ATP production,and increasing use of glucose and oxygen [25]. Vincamine has also been usedto treat a remarkable variety of conditions related to insufficient blood flowto the brain, including vertigo and Meniere's syndrome, difficulty insleeping, mood changes, depression, hearing problems, high blood pressure,and lack of blood flow to the eyes [26]. Vincamine has also been used forimproving memory defects and inability to concentrate. Vincamine hasextremely low toxicity and is inexpensive.
Hydergine is reported to increase mental abilities, prevent damage to brain cells from hypoxia, and may even be able to reverse existing damage tobrain cells. Hydergine is an extract of ergot, a fungus that grows on rye [27].
Midwives in Europe traditionally used ergot with birthing mothers to lowertheir blood pressure. Scientists have analyzed ergot alkaloids since the late1940s in search of blood-pressure medications. Studies in the elderly pop-ulation uncovered cognition-enhancing effects of Hydergine and it is now apopular treatment for all forms of senility in the United States, and is usedto treat a plethora of problems elsewhere in the world.
Hydergine probably has several modes of action for its cognitive- enhancement properties. Its wide variety of reported effects includes thefollowing: increases blood supply and oxygen to the brain, enhances braincell metabolism, protects the brain from free-radical damage duringdecreased or increased oxygen supply, and reduces symptoms of dizzinessand tinnitus [28].
Hydergine may cause mild nausea, gastric disturbance, and headache.
There are no serious side effects reported with Hydergine use. It is nontoxiceven at very large doses. It is contraindicated for individuals with acuteor chronic psychosis, however, or those with a known sensitivity to themedication. Overdosage may, paradoxically, cause an amnestic effect.
Hydergine is available in the United States with a prescription. Hydergine has not undergone rigorous scientific tests to prove its effectiveness fortinnitus reduction. In Europe, however, many patients have been usingHydergine with good success in relieving their symptoms.
M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 Patients who suffer from the condition of tinnitus have the opportunity to explore the horizon of CIM in pursuit of a treatment regimen that mayrelieve many of their agonizing symptoms. As is the case in the treatment ofother chronic diseases, conventional pharmacotherapy represents only oneavenue on which the physician may venture. In an attempt to relieve thesymptoms that plague the common tinnitus patient, the patient may want toexplore nonconventional treatment options.
For more than 2000 years, herbal regimens have been used in the treatment of medical conditions [28]. Combinations of Chinese herbs,exotic fruits, plant roots, and seed oils have proved to be effective in thetreatment of many medical disorders where conventional medical therapyhas failed. What many of these herbal treatment regimens lack is solidmedical evidence in the form of double-blind research experiments, whichlegitimize the use of these nonconventional treatments. To the sufferingpatient whose treatment regimens have been met with failure, however,perhaps anecdotal accounts of effective treatments are proof enough tojustify an alternative approach.
Gingko biloba, or maidenhair, is the oldest living tree on earth. G. biloba leaves have been used therapeutically by the Chinese for centuries for thetreatment of asthma and bronchitis. G. biloba was believed at one timeto have magical powers. Today, ginkgo is believed by many to havea legitimate medicinal role. The important components of ginkgo areflavonoids and terpenoids. These have been shown to inhibit the action ofplatelet-activating factor. The putative active ingredient has been isolatedas EGB761 and there have been many studies related to its effectiveness ina variety of medical disorders [29]. It has been shown to increase cir-culation throughout the body. Numerous studies have shown the efficacyof ginkgo on intermittent claudication, cerebral insufficiency, and tinnitus[30].
Typical dosages range from 120 to 480 mg/d, divided equally at mealtime.
In western countries a standardized 50:1 concentrate of 24% gingkoflavonoids is used, either in liquid or capsule form. Most studies showed thatbetween 30% and 70% of subjects had improved cognitive abilities over a 6-to 12-week period [29]. No serious side effects were observed, and any minorside effects were not statistically significant compared with subjects treatedonly with placebo.
In terms of tinnitus, a study by Hobbs [29] in 1986 provided statistical significance for the effectiveness of treatment with ginkgo extract fortinnitus; the ringing completely disappeared in 35% of the patients tested,with a distinct improvement in as little as 70 days. Similarly, when 350 M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 patients with hearing defects caused by advanced age were treated withginkgo extract, the success rate was 82%. Furthermore, a follow-up study of137 of the original group of elderly patients 5 years later revealed that 67%still had better hearing [30].
Opinions differ as to the efficacy of this herbal remedy. Whereas certain sufferers of tinnitus swear by G. biloba, others claim that it has no effect ontheir symptoms. The results of the first large-scale double-blind randomizedprospective study (1121 volunteers at Birmingham University in the UnitedKingdom) on the efficacy of ginkgo in tinnitus treatment was published in2001. The patients in this study received either 150 mg of ginkgo or placeboin a randomized fashion for 12 weeks. The results did not show a significanteffect in treating tinnitus; however, the dose used was approximately 65%less than what has been shown to be of benefit [31].
Published studies have shown that 120 to 240 mg twice per day of pharmaceutical-grade ginkgo extract can alleviate tinnitus [32]. A controlledstudy showed that ginkgo extract caused a statistically significant decrease inbehavioral manifestation in the animal model of tinnitus. Another humanstudy showed that in patients suffering from cerebrovascular insufficiency,gingko extract produced a significant improvement in symptoms of vertigo,tinnitus, headache, and forgetfulness [26,29].
One of the appealing aspects of G. biloba with regard to the treatment of tinnitus has been the fact that it is relatively inexpensive, and has negligibleside effects, such as increase risk for epistaxis. There has been one reportof a woman who used ginkgo for approximately 2 years who developed asubdural hemorrhage [9]. This substance, however, has been used for morethan 2000 years without severe side effects. As with any medication, thephysician should take a careful history before recommending gingkobecause it may potentiate hemorrhage in people taking warfarin or heparin.
The German Commission E, which is considered an excellent reference forthe medicinal use of therapeutic herbs, rates ginkgo as positive and recom-mends 240 mg twice per day for tinnitus and vertigo [26]. The responseto ginkgo can occur within weeks, but is most noticeable within 3 to 4months.
Combined application of soft-laser irradiation of the cochlea and intravenous supply of ginkgo extract for 4 weeks was found to be beneficialin 20% to 50% of patients in one study [33]. The mechanism of the soft laseris unknown, but it is known to cause an athermic stimulation of biochemicalprocesses induced by light. Increased ATP production occurs in yeastfungus cultures irradiated with the soft laser, yet it is unclear if it is this samemechanism in human inner ear cells. Soft-laser–ginkgo therapy promised tobe very effective in chronic tinnitus. Ginkgo provides a better oxygen supplyand the laser acts directly on the flavoproteins to activate repair mech-anisms. Plath and Olivier [33] showed that in single cases, tinnitus reduc-tion can be attained and they deduced that combined soft laser and gingkoapplication can be helpful in some patients suffering from severe tinnitus.
M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 Wedel et al [34], however, showed no significant improvement with thesetreatments compared with placebo.
The variable response to herbs including gingko raises the concern of whether all preparations are the same. In the senior author's experience, it isclear that some of the less expensive brands were ineffective and had a higherrate of gastrointestinal upset. When these patients were then changed toa more respected or well-known brand, these side effects were amelioratedand the patients' response typically was better. Over the past several years,we have been recommending Arches Tinnitus Relief Formula (, because their formulation is highly standardized andseems to be effective for some patients. Ginkgo is not effective in everypatient with tinnitus, but the risk to benefit ratio suggests that a trial withginkgo is reasonable.
Black cohosh (Cimicifuga racemosa) The popular herb black cohosh comes from the root of the North American forest plant Cimicifuga racemosa. It derives its name from adescription of the rhizome, which is black and rough. Also known as blacksnakeroot, bugbane, bugwort, and squawroot, black cohosh has an exten-sive history of safe use by Native Americans who revered it as a remedyfor a host of common ailments [26]. Native Americans used black cohoshas an effective treatment for fatigue, neuralgia, rheumatism, sore throat,asthma, bronchial spasms, bronchitis, and whooping cough. Mixed withchamomile, ginger, and raspberry leaf, black cohosh has been used forcenturies by women to stimulate menstrual flow, ease the strains of child-birth, and confer relief from the symptoms of menopause.
Contemporary herbalists also hold black cohosh in high regard as an antispasmodic for relief from cramps, muscle pains, and menstrual pains.
With its mildly sedative and relaxing effect, black cohosh is also used to treatanxiety, nervousness, and chronic tinnitus. Some patients have reportedimprovement in their tinnitus while using this herbal preparation.
The active ingredients in black cohosh seem to be chemical derivatives mimicking some of the effects of estrogen. It was also found to contain theglycoside acetein, a steroidal derivative that is effective in lowering bloodpressure in animals [4]. Black cohosh also contains compounds that supportits use as a sedative and as an anti-inflammatory agent.
There are few known health concerns regarding black cohosh, but con- suming large amounts is known to cause nausea, dizziness, and vomiting.
Expectant mothers should only use black cohosh under the supervisionof a health professional, because it has a reputation of stimulating theuterus to contract, and large doses could lead to premature birth. Blackcohosh has traditionally been used to calm the nervous system by nourish-ing blood vessels [3] and it is theorized that it may improve cerebral M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 blood flow, providing relief from tinnitus in some patients. Dosages rangefrom 20 to 40 mg/d in liquid form for this ailment.
Mullein (Verbascum densiflorum) Mullein is ubiquitous, and its velvety leaves, rod-like stem, and brilliant yellow flowers are its striking characteristics. Mullein has a long history ofuse in herbal medicine. Its botanical family name (Scrophulariaceae) is de-rived from scrofula, an old term for chronically swollen lymph glands, lateridentified as a form of tuberculosis. Initially, this herb gained a favorablereputation as a respiratory remedy. Physicians from India to England toutedit as a treatment for coughs and chest congestion, alleviating irritation,earaches, and tinnitus [35].
In a 1986 survey of folk medicine in Indiana, researchers discovered that this herb remains very popular for respiratory complaints [35]. There hasbeen little research on mullein itself, and even less research into its treatmentof tinnitus. Some herbalists have shown benefit in patients suffering fromsevere tinnitus, however, claiming it to be very valuable. Mullein seems tohave a slight diuretic effect and may alleviate inflammation. To brew amedicinal tea, use one to two teaspoons of dried leaves per cup of boilingwater. Boil for 10 minutes and strain leaves. One teaspoon contains approxi-mately 0.5 g of the drug. The dosage reported to provide relief from tinnitusseems to be 3 to 4 g/d. There have been no reports of mullein causingadverse effects, except for mild irritation of the skin when in contact with theliving plant [4].
Cornus, which is also known as Asiatic cornelian cherry fruit and Asiatic dogwood, is grown in several parts of China. The fruit is harvested in Octoberand November when it becomes purplish red, and is fat, thick, soft, andseedless. Available at Chinese pharmacies, Asian food markets, and someWestern health food stores, cornus is taken internally for excessive urination,incontinence, impotence, lightheadedness, excessive sweating, and excessivemenstrual bleeding. Formerly, it was in use as a replacement for quinine [3].
Preparation of the combination formula alluded to, which is used in thetreatment of tinnitus, requires the consultation of an herbalist. Chineseherbalists advise against the usage of cornus in combination with severalother herbs, including platycodon, siler, and stephania.
Cornus (Cornus officinalis) alone does not seem to relieve the symptoms of tinnitus, but when used in combination with Chinese foxglove root andChinese yam proves to be effective in the treatment of tinnitus, low-backpain, and urinary frequency [4].
M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 Wobenzym is a group of proteolytic enzymes including pancreatin, tryp- sin, chymotrypsin, bromelain, papain, and rutosid. It was initially developedby Ransberger in 1959 with MUCOS Pharma to fight cancer. Ransbergerbrought the formula to Germany and since then has pioneered the medicaluse of the systemic enzymes. This remedy has shown effectiveness for ar-thritis, throbbing pains, and tinnitus. It seems to be an alternative to aspirinand has shown some benefit to recovering from a myocardial infarction [36].
Studies in Europe have been conducted on Wobenzym, backing the findings of Ransberger. Studies show Wobenzym to be safe with none of theadverse side effects of aspirin, ibuprofen, and other nonsteroidal anti-inflammatory drugs [37]. It has also been shown to improve red blood cellviscosity, improve circulation to damaged areas, and have anti-inflamma-tory properties [37]. Whether or not Wobenzym can positively influence thesymptom of tinnitus has not been adequately studied, but some patientshave noted relief.
In the cochlea, all of the auditory processes require energy in the form of ATP. ATP is produced by the mitochondria inside each cell. If the cochlea isacutely or chronically overstrained, its sensory cells and their various cel-lular organelles also are affected, and they inevitably lose part of their func-tional capacity. The cells may suffer from a lack of ATP. This continuouslack of ATP within the inner ear cells of the cochlea leads either to a gradualor sudden impairment of the entire hearing organ.
Using low-level laser therapy, Wilden in Germany has been able to produce a positive biologic reaction regardless of the dysfunction involved in the innerear. The electromagnetic energy released by the oxidation of nutrients is usedas a source of primary energy for the production of the cellular fuel ATP.
The mitochondria can, in addition to the absorption of the released metabolic energy, use both the photons of the natural solar radiation(apparent biostimulative effect of sunlight on human cells) and the photons oflow-level laser light as a source of primary energy. Wilden uses two separatebeams on the mastoid bone and one beam down the ear canal simultaneously.
This delivers a calculated 4 J/cm2 to the cochlea [38]. The additional ATPtriggered by the light may have some healing value for the damaged inner earhair cells. This therapy may be more beneficial in patients in the early stages oftinnitus because it may have more benefit in damaged cells than dead ones.
Betahistine hydrochloride, also known as Serc, is not approved for use in the United States. This drug has been used in Canada and Europe for patients M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 with severe vertigo from Meniere's disease and in some patients suffering fromtinnitus. Betahistine was found to have a histamine-like action in animals.
The usual starting dose is 4 mg three times per day and may increase up to 48 mg/d. Side effects include headaches (usually in the first 1 to 3 daysof treatment) and it is relatively contraindicated in patients with ulcer dis-ease. Some studies in the past have shown efficacy in treating vertigo and tin-nitus. An abstract by Martin [39] compares betahistine, pentoxifylline, andxantinol-nicotinate in the treatment of tinnitus. Using 172 patients, theresults showed that those receiving betahistine produced significantly bettertherapeutic results in eliminating their tinnitus.
Vibrational therapy Tinnitus may arise from damage to the microscopic endings of the hearing nerve in the inner ear. The health of these nerve endings is importantfor acute hearing, and injury to them brings on hearing loss and tinnitus.
Advancing age is generally accompanied by a certain amount of hearingnerve impairment and often tinnitus.
A device has been developed in Europe by DiMino. He suffered from tinnitus and pioneered the Aurex-3 (ADM Tronics Unlimited, Inc., North-wale, NJ), which stimulates the damaged nerve endings in a broadbandfrequency surrounding the frequency of the tinnitus. Eventually the brain isretrained to not reproduce the original tinnitus sound at the same intensity.
Mechanical vibrations are generated in the applicator and transmitted into the cochlea by placing the probe in front of the mastoid bone justbehind the ear. A primary vibration is applied and its frequency tuned untilit best matches or masks the tinnitus sound. Because different parts of thecochlea operate at different frequencies it is important to ensure that thetreatment is targeting the damaged area within the ear. The amplitude ofvibration is then raised to a tolerable level for the patient, increasing theenergy applied to the damaged area.
The manufacturers of Aurex-3 recommend initial treatments of 3 to 5 minutes' duration, three to four times a day. Immediate relief is rarelyexperienced but after regular use of 4 to 6 weeks' period, relief should besufficient to reduce the frequency of ongoing treatments. For those peoplewho experience unilateral tinnitus, treatment in just one ear is appropriate.
For those who experience bilateral tinnitus or tinnitus inside their head,however, it is recommended that both ears be treated.
The Aurex-3 represents a new alternative for the potential relief from tinnitus. Experience from use of this device has shown good results and onthe basis of subjective evidence the Aurex-3 is being promoted as a newdevelopment in the treatment of tinnitus.
Clinical trials are now underway to more substantiate evidence of these results and to determine precisely the effectiveness of effective Aurex-3.
Trials are being conducted in the United States and in Europe [40].
M.D. Seidman, S. Babu / Otolaryngol Clin N Am 36 (2003) 359–381 Tinnitus retraining therapy Jastreboff and Jastreboff [41] have developed a therapy technique called tinnitus retraining therapy, which has provided significant improvement forat least 80% of tinnitus sufferers. Tinnitus retraining therapy is based onstrong neurophysiologic evidence that any person can habituate to acoustic,or acoustic-like, sensations in their environment.
Tinnitus retraining therapy has two key elements: directive counseling and sound therapy. The counseling session is critical to the success of theprogram, and patients may actually achieve relief through counseling alone.
The counseling process involves an in-depth discussion of the hearingphysiology, which helps the patient understand why tinnitus occurs. Hear-ing only starts at the ear; from there, sound signals travel to the lowestlevels of the brain (brainstem) and pass upward to arrive eventually at thehighest level of the brain, the auditory cortex. Random signals in theseareas may be responsible for the perception of tinnitus. A strong nega-tive emotional reaction to the tinnitus causes it to be a problem. An ex-panded discussion about the auditory process enlightens patients and helpsrelieve their fears.
In addition to counseling, most patients are fitted with ear-level white noise devices. These look like small hearing aids and are comfortably wornduring the day. The sound is set to a very low level, which never interfereswith normal hearing, and after several weeks most patients do not hear thesound unless they really try to hear it. These devices help the brain to ignorethe random signals of tinnitus, achieving auditory habituation.
The initial evaluation and counseling process is quite extensive, usually lasting 4.5 to 5 hours. Regular follow-up visits or telephone communi-cation for out-of-town patients are absolutely necessary. Within 6 to 24months many patients have eliminated or are no longer bothered by theirtinnitus.
Tinnitus is a significant medical problem affecting approximately 50 million Americans, 12 million of them severely. Once a thorough evaluationhas been performed by a qualified otolaryngologist, and no life-threateningpathology has been identified, the opportunity for treatment exists.
Treatment options are extensive and range from approved protocols toanecdotal remedies. Although tinnitus may not miraculously disappear,many therapeutic options exist that may help to make the tinnitus moremanageable.
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February 2015 newsletter final

הרוםמה תרשרש "Chain of Tradition" The Newsletter of Traditional Congregation February-March 2015 Shevat-Adar 577 ‘ שת ןסינ ט Mark Your Calendars "Lunch and Schmooze with Rabbi Gordon" Tuesday, February 10 12 noon Wednesday, March 11 12 noon Join Rabbi Gordon for a relaxed lunch and schmooze—anything Jewish goes! See page 10 Knosh & Knowledge Brunch & Program

SEMINARIOS DE INNOVACIÓN EN ATENCIÓN PRIMARIA. INTELIGENCIA SANITARIA APLICADA A LA CLÍNICA: ¿POR QUÉ HACEMOS LO QUE HACEMOS? Javier Padilla BernáldezM.I.R. 3er año Medicina Familiar y Comunitaria.C.S. Castilleja de la Cuesta. Sevilla. ¿POR QUÉ HACEMOS LO QUE HACEMOS? "Ninguno de nosotros sabía que éramos